A study of association between early menarche and anxiety in undergraduate students

Background Anxiety has been reported to be one of the most common epidemics in recent years. The present study focused on understanding the association between early menarche and the prevalence of anxiety and anxiety symptoms among adult undergraduate students. Methods This was an observational, case-control study. The sample included 146 young female adults aged more than or equal to 18 years pursuing the Bachelor of Medicine and Bachelor of Surgery (MBBS) and Bachelor of Dental Sciences (BDS). Using an online questionnaire, participants were asked to recall and enter the age at which they attained menarche. We used the Generalized Anxiety Disorder 7- Item Questionnaire (GAD-7) to measure the severity of their present anxiety symptoms. Results The results showed a significant increase in anxiety symptoms in participants who had early menarche compared to those who did not have early menarche. The mean score on the GAD-7 Questionnaire for the cases was 9.93 and the control group was 6.89. The GAD-7 scores among the cases group were significantly higher in the GAD-7 scores than in the control group. Conclusions This study concluded that early menarche is associated with higher anxiety levels in young adults.

This was an observational, case-control study.The sample included 146 young female adults aged more than or equal to 18 years pursuing the Bachelor of Medicine and Bachelor of Surgery (MBBS) and Bachelor of Dental Sciences (BDS).Using an online questionnaire, participants were asked to recall and enter the age at which they attained menarche.We used the Generalized Anxiety Disorder 7-Item Questionnaire (GAD-7) to measure the severity of their present anxiety symptoms.

Results
The results showed a significant increase in anxiety symptoms in participants who had early menarche compared to those who did not have early menarche.The mean score on the GAD-7 Questionnaire for the cases was 9.93 and the control group was 6.89.The GAD-7 scores among the cases group were significantly higher in the GAD-7 scores Any reports and responses or comments on the article can be found at the end of the article.

Introduction
Anxiety is the world's most common mental health disorder, affecting 301 million people worldwide in 2019.It has also been reported that women are affected more by anxiety disorders than men, and their symptoms surge during childhood or adolescence.It is also stated that approximately one in four people with anxiety disorders receive treatment, which reflects that only a minority of the population affected is receiving adequate healthcare. 1 The United Nations Sustainable Development Goal (UN SDG 3) focuses on good health, which includes mental health, whereas the UN SDG 5 focuses on gender equality.An intersection between these two goals is the mental health of women, which has long been neglected, leading to a gap in the quality of the healthcare provided to men and women.
To bridge this gap, it is imperative to study the factors affecting mental health specific to women. 2 In recent decades, there has been a trend of decreasing mean age at menarche in India. 3Early menarche is defined as menarche at or below 12 years of age. 4 Eating habits and a higher body mass index have been implicated as risk factors for early menarche. 4berty is a formative period during which several hormonal, reproductive, and social changes occur.The psychological effects of early puberty may not be limited to adolescence but may also affect mental health during adulthood. 5study conducted on secondary school female students aged 12 to 17 years reflected the association between menarche and the prevalence of anxiety and depression comorbidities. 6udies have evaluated the difference in the effect of pubertal timing between males and females.While early puberty tends to have a positive impact in males, it is linked to increased symptoms of depression among females. 7cial stress after puberty and changes in peer, sexual and family connections have been linked to emotional issues in early adolescence. 7,8e long-term developmental consequences of pubertal timing reported that girls who mature early continue to have a higher risk of anxiety throughout adolescence and early adulthood. 9,10Because early menarche leads to an abrupt transition, it leaves little time for emotional preparation.Girls who mature early may experience anxiety and related symptoms. 11veral studies have reported an association between early menarche and psychosocial pathologies in adolescents.Early menarche is associated with increased substance abuse, elevated depression, and suicidal behaviors in adolescent girls. 12,13e effect of early menarche on mental health in adulthood remains controversial.Some studies have shown that early menarche is associated with depressive symptoms and antisocial behavior in adults, 14 while other studies have shown that there is no association between early menarche and symptoms of depression. 15An association has been found between anxiety disorders in adult women and early perceived pubertal timing. 16VISED Amendments from Version 1 The major differences between this version and the previously published version are as follows: Improvisation in discussion: Responding to the feedback on discussion based on the review, we have expanded the discussion on guidance, communication and support during puberty.We have discussed regarding the effect of social and cultural environment.We have highlighted the link between traumatic events and anxiety.
Revision to limitations: We have revised the limitations by elaborating on the limitations and additional limitations based on the reviews.We have also elaborated on the directions for future research which can address this limitations like larger sample size, generalizability, reporting bias, study design, assessing the confounding factors like socioeconomic status, genetic predisposition, lifestyle, family history of anxiety disorders, other medical conditions, formal/informal guidance received regarding pubertal changes and perceived support during menarche, family environment, temperament, traumatic experiences.
Revision to conclusion: We have highlighted the practical implications of this study in addition to the previous conclusion.
Any further responses from the reviewers can be found at the end of the article The fluctuation of estrogen levels during the reproductive lifespan of women has been frequently studied and linked to various psychiatric disorders. 17However, the role of estrogen in anxiety has not been determined.Increased anxiety levels are observed during menarche, which is the time at which estrogen levels become elevated. 6In contrast, animal experiments have shown that acute and chronic estrogen administration have anxiolytic effects. 18Estrogen acts through three estrogen receptor (ER) subtypes, which have different effects on anxiety.Estrogen Receptor alpha (ER alpha) has anxiogenic effects, estrogen receptor beta (ER beta) has anxiolytic effects, and G protein-coupled estrogen receptor (GPR30) has both anxiolytic and anxiogenic effects. 195][16] We aimed to understand whether there is an association between early puberty and anxiety symptoms in women aged more than or equal to 18 years.Age at menarche was chosen for this study because it is an objective measurement.We selected undergraduate students pursuing Bachelor of Medicine and Bachelor of Surgery (MBBS) and Bachelor of Dental Sciences (BDS), as it was presumed that academic stressors among these students may be similar, thus reducing an important confounding factor.

Aims
This research aimed to understand the relation between early menarche and anxiety during adulthood.

Study setting:
The study was conducted in Kasturba Medical College and Hospital, Mangalore.
Study design: This study was conducted as an analytical observational case control study.
Study participants: Female undergraduate students studying in Kasturba Medical College, Mangalore and Manipal College of Dental Sciences, Mangalore.

Inclusion criteria
Cases: 1. Age more than or equal to 18 years

Sample size
The estimated sample size for the study was 76 for each group, with 5% significance level and 80% power.The total sample size estimated for the study was 152 participants.
96 is a standard normal value for 95% confidence interval Z1 β = 0.84 is a standard normal value at 80% power Sampling method: Convenient sampling method

Methodology
The study questionnaire was uploaded and shared online on Google Forms.A link to the electronic questionnaire was distributed in the college campus via e-mail, WhatsApp, and Online class groups.The questionnaire had an introductory page describing the background and aims of the study, ethical information for the participants, and informed consent.
Once the participant clicked on the 'I agree' button, they were directed to the next sections of the questionnaire.
Participants were able to leave the questionnaire at any stage before the submission process.If they left in between, their responses were not saved.Responses were saved only by clicking on the 'submit' button.By completing the questionnaire, participants acknowledged their voluntary consent to be included in the study.

Tool for data collection
The questionnaire had the following sections.
Section A: General participant information This contains the sociodemographic information of the participants, including age, place of residence, and so on.
Section B: Age at menarche and menstrual history This consists of age at menarche based on recall, history of dysmenorrhea, any known thyroid disorder, and any known gynecological disorder.
Section C: Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire 20 The GAD-7 Scale is a seven-point scale commonly used to assess anxiety in clinical as well as educational settings.
Participants marked their answers on a scale of not at all, several days, more than half the days, and nearly every day.
The GAD-7 score is calculated by assigning scores of 0 to "not at all," 1 to "several days," 2 to "more than half the days," 3 to "nearly every day."Thus, the scores range from 0 to 21.The interpretation of the score would be 0-4, minimal anxiety; 5-9, mild anxiety; 10-14, moderate anxiety; and 15-21, severe anxiety.

Section D: Anxiety symptoms
In this section, further questions were asked regarding the duration and treatment of anxiety symptoms experienced by the participants.
A copyright licence was obtained by the institution.
Statistical significance was set at p value<0.05.Descriptive statistics such as mean, proportions, and standard deviation were used to express the results.The t-test was used for continuous variables, and the chi-square test was used for categorical variables.

Results
The present study comprised a total of 146 participants after excluding participants who did not adhere to our inclusion and exclusion criteria.
The age of the participants in our study ranged from 18 to 25 years.The mean age was 20.54AE1.7 years.
The age at menarche of the participants ranged from 10 to 16 years.The mean age at menarche of our participants was 12.48AE1.17years.
The participants were grouped into case and control groups based on age at menarche.The participants with age at menarche less than or equal to 12 years were the cases and the control group consisted of participants with age at menarche greater than 12 years.We had 74 participants in the cases group and 72 participants in the control group.
The mean score for the cases on the GAD-7 questionnaire was 9.93 (Standard deviation=6.05).The mean score for the controls on the GAD-7 questionnaire was 6.89 (Standard deviation=5.24).An independent t-test was performed, and it was found that the GAD-7 scores of the cases were significantly higher than the GAD-7 scores of the controls with a (t(144)=3.26,p<0.05).Thus, the difference in the GAD-7 scores between the cases and controls was found to be significant.
In the cases, 66 of 74 participants entered their age at the onset of anxiety symptoms.Among the controls, 56 out of 72 participants entered their age at the onset of anxiety symptoms.These findings are summarized in Table 1.
Among the cases out of 74 participants, 65 responded to the question regarding the duration of their anxiety symptoms.Among the controls, 55 out of 72 participants responded to questions regarding the duration of their anxiety symptoms.The findings regarding the duration of the anxiety symptoms are summarized in Table 2.
Of the 146 participants in the present study, 122 answered the question regarding whether they had received treatment for their anxiety symptoms.20.5% had received treatment for their symptoms.Thirty participants reported details of the treatment they received.Of these, 12 participants (40%) received pharmacological treatment, 16 (53.3%)received psychological treatment, 1 (3.3%) received both psychiatric and Ayurvedic treatment, and 1 (3.3%) received crystal stone treatment.
Among 146 study participants, 26 participants reported to have known gynecological condition, among them 23 reported to have polycystic ovarian syndrome.Six participants reported to have known thyroid condition.

Discussion
The present study focused on the association between early menarche and anxiety during adulthood.This was an analytical observational case-control study of female undergraduate students aged more than or equal to 18 years.
The mean age at menarche in our study was 12.48AE1.17years.Their ages ranged from 10 to 16 years.The mean age at menarche was found to be lower than the mean age at menarche in India calculated as of 2005 which was 13.76 years. 3ore recently, studies have shown a decline in the mean age at menarche between mothers and daughters. 22A study conducted among North Indian girls in 2023 found the mean age of menarche to be 13.13AE1.23years. 23The mean age at menarche in our study was found to be even lower than these.
The present study found that anxiety symptoms were significantly higher in participants with an early age at menarche.0][11][12][13] Other studies have found that females who mature early are more likely to experience symptoms of psychiatric illnesses, including anxiety, throughout adolescence and during the early stages of adulthood. 9,10otional problems in early adolescence have been connected to social stress following puberty and modifications in peer, sexual, and family relationships. 7,8It is evident that in females, menarche becomes a sudden transition that provides little time for emotional preparation and can cause anxiety and related symptoms. 11During the perimenarcheal phase, participants described feeling puzzled, worried, and ambivalent, but eventually acclimated to these changes. 11e relationship between mental health and early puberty is complex.In this study, we did not address some factors which may also affect the mental health of women during puberty and as young adults.The psychological effects of early puberty have been attributed to the social and cultural environment. 24Factors like race and ethnicity have also been found to play a role. 25In this study we did not consider the cultural background of the participants which could also play a role.
Another study conducted in India, showed that girls who were communicated with regarding taboos associated with menstruation showed greater stress about staining. 26Such studies emphasise the need for accurate and effective communication in order to promote the emotional and mental health of adolescent girls.
Our study also did not consider the traumatic childhood experiences of the participants.Traumatic events during childhood have been linked with early puberty in girls. 27Traumatic events have also been linked to increased risk of both cardiovascular disease as well as anxiety. 27,28ile our study was conducted on adult undergraduate students, it is important to also understand the potential reasons for poor mental health among girls during puberty so that we can prevent the development of mental health disorders.A study found that girls who achieve menarche earlier are less prepared for puberty and tend to have more negative emotions associated with menstruation. 29Parental support has been found to be related to more preparedness among girls during menarche. 30Motivational interviews and peer groups have also been found to be effective tools in promoting the mental health of adolescent girls as well as their knowledge about puberty. 31On the other hand, while girls who achieve menarche early have poorer mental health outcomes, they use less non-productive coping strategies when compared with their peers. 32This is encouraging and shows that even though there are emotional challenges associated with early menarche, using the right tools can help ease this transition for girls.
The findings of this study can also be explained by estrogen variations in women.4][35] Menarche, the period when estrogen levels rise, is associated with higher anxiety levels. 17However, the anxiolytic effects of both acute and chronic estrogen treatments have been demonstrated in animal models. 18Estrogen has distinct effects on each subtype of the receptor through a complex interaction. 19This study followed an objective metric, age at menarche, to investigate the relationship between anxiety during adulthood and early puberty.
Among the cases, 20.3% had minimal anxiety, 32.4% had mild anxiety, 21.6% had moderate anxiety, and 25.7% had severe anxiety.Among the controls 38.9%, 30.6%, 25.0% and 5.6% had minimal, mild, moderate, and severe anxiety, respectively.A larger percentage of the women in the case group experienced severe anxiety.However, a greater percentage of the women in the control group experienced minimal anxiety.
In our study, we found that 59.1% of cases and 67.9% of controls first experienced anxiety symptoms after 18 years of age.In contrast, 27.3% of the cases and 25% of the controls first experienced anxiety symptoms between the ages of 14-17 years of age.A previous study found that the mean age of onset of generalized anxiety disorder was between 21.1 and 34.9 years. 36However, this was only partially reflected in our study, probably because the mean age of our participants was 20.54AE1.7 years.
According to our study, the duration of anxiety symptoms was less than 6 months in 30.8% of cases and 32.7% of controls.The duration of anxiety symptoms was between 6 and 12 months in 16.9% of cases and 29.1% of controls.The duration of anxiety symptoms was greater than one year in 52.3% of the cases and 38.2% of the controls.A study found the mean duration of anxiety symptoms to be 15.2 months, 37 which was in line with our findings.
Of the 122 participants who answered the question, 20.5% received treatment for their symptoms.A study by the World Health Organization on the treatment gap in anxiety disorders also showed that only 27.6% of the respondents who had anxiety disorder had received treatment of any form, and only 9.8% had possibly received adequate treatment.It is evident that there is a need to diagnose anxiety disorders and improve the treatment quality. 38 the participants who reported receiving treatment, 12 participants (40%) received pharmacological treatment, 16 (53.3%)received psychological treatment, 1 (3.3%) received both psychiatric and Ayurvedic treatment, and 1 (3.3%) received crystal stone treatment.In general, the first-line treatment for generalized anxiety is cognitive behavioral therapy (CBT) and pharmacotherapy (SSRIs, SNRIs).Others include benzodiazepines for acute cases, metacognitive therapy, mindfulness techniques, physical activities, and Acceptance and Commitment Therapy). 39Most participants in our study relied on allopathic treatments, whereas a minority resorted to alternative treatment methods.
This study sheds light on anxiety symptoms associated with early menarche.Further implications of this study include understanding other psychiatric comorbidities associated with early menarche and puberty.

Limitations
This study was conducted at a single medical college and dental sciences college in Mangalore and used convenient sampling.This sample may not represent the diversity of backgrounds and health conditions in the broader population.Further studies should be done with a larger sample size and considering the various backgrounds of participants to increase generalizability.
The inclusion criteria (e.g., willingness to participate, ability to recall age at menarche) and exclusion criteria (e.g., age less than 18 years) could have introduced selection bias, as they may have excluded certain groups that could affect the generalizability of the study.
Although this study used the GAD-7 questionnaire which is a widely used standardised self-reporting questionnaire, selfreported data for variables such as anxiety symptoms and treatment history are subject to reporting bias.Participants may under-report or over-report symptoms depending on various factors such as stigma or social desirability.
The study's cross-sectional design limits its ability to establish causal relationships between early menarche and anxiety.Longitudinal studies would be necessary to determine whether early menarche precedes and predicts higher levels of anxiety over time.
The study did not explore potential confounding factors comprehensively (e.g., socioeconomic status, genetic predisposition, lifestyle, family history of anxiety disorders, other medical conditions, formal/informal guidance received regarding pubertal changes and perceived support during menarche, family environment, temperament, traumatic experiences), which could influence the relationship between early menarche and anxiety.
Addressing these limitations in future research could strengthen the validity and reliability of findings regarding the association between early menarche and anxiety disorders among female undergraduate students.

Conclusion
This study suggests a significant association between early menarche (age ≤ 12 years) and higher levels of anxiety among female undergraduate students.The findings of this study support the hypothesis that early physiological development could contribute to increased vulnerability to anxiety in young adults.This knowledge could help healthcare providers give the required support to girls during puberty as well as young adult women.Recognizing early menarche as a potential marker for heightened anxiety risk could guide preventive measures and mental health interventions tailored to young women during critical developmental stages.It could also help understand the potential factors which may have contributed to the development of anxiety in young adults.Hence, there is a need for healthcare providers to be sensitized to early pubertal timing in adults with anxiety.
In summary, while the study provides evidence of a significant association between early menarche and increased anxiety levels among adult female undergraduate students, further research is needed to elucidate the underlying mechanisms and causal pathways.These findings underscore the importance of early detection and support for mental health issues in young women experiencing early puberty.

Pre-registered data analysis
The data analysis in this study was not pre-registered.Reviewer Expertise: Public health, Infectious Diseases and non communicable diseases I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Sanjeev Badiger
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2 . 1 .
Age at menarche less than or equal to 12 years 3. Undergraduate students willing to consent for the study Controls: Age more than or equal to 18 years 2. Age at menarche greater than 12 years 3. Undergraduate students willing to consent for the study Exclusion criteria Cases and controls 1.Age less than 18 years 3. Participants unwilling to give consent 4. Incomplete filling of questionnaire 5. Participants who could not recall age at menarche Study duration: The study was conducted over 7 months, from June 2023 to December 2023.

A
J Institute of Medical Sciences and Research Centre, Mangaluru, India The topic selected is novel , but more details could have added regarding matching.Other factors like socioeconomic conditions and environmental factors could have been added to avoid bias but this was mentioned in the limitation of the study Results and discussion part: satisfactory with good number of references Limitations of the study: Mentioned about the limitations Is the work clearly and accurately presented and does it cite the current literature?Yes Is the study design appropriate and is the work technically sound?PartlyAre sufficient details of methods and analysis provided to allow replication by others?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesAre the conclusions drawn adequately supported by the results?YesCompeting Interests: No competing interests were disclosed.

Table 1 .
Age of onset of anxiety symptoms among cases and controls.

Table 2 .
Duration of anxiety symptoms among cases and controls.Statistical analysis was performed using IBM SPSS Statistics for Windows version 29 (IBM Corp., Armonk, N.Y., USA).